Thomas A. Heafner

Initial management and outcome of modern battlefield anal trauma.

BACKGROUND: Despite the potential for morbidity and permanent lifestyle alteration, few reports exist examining traumatic injury to the anal canal, particularly among modern-day combatants. OBJECTIVE: The aim of this study was to document the incidence, initial surgical management, and long-term outcomes of wartime anal trauma. DESIGN: This study is a retrospective review. DATA SOURCES: Data were compiled from multiple electronic medical record systems, including the Department of Defense Trauma Registry, the Patient Administration Systems and Biostatistics Activity, and the Armed Forces Health Longitudinal Tracking Application. SETTINGS: Combatants were treated at military treatment facilities with surgical capability during the wars in Iraq and Afghanistan, 2003 through early 2011. PATIENTS: All US and coalition combatants sustaining trauma to the anal canal or sphincter musculature were included. MAIN OUTCOME MEASURES: The quantification of incidence, the evaluation of initial treatment approach, and the determination of clinical and surgical factors correlating with restoration or preservation of GI tract continuity were the primary outcomes measured. RESULTS: Anal trauma occurred in 46 combatants, predominantly from blast injury (76.1%). Most (36, 78.2%) underwent fecal diversion. Concurrent severe systemic or intra-abdominal injuries correlated with colostomy creation. Acute anoplasty was attempted in 11 patients (23.7%) but did not influence eventual colostomy reversal. Among 33 US personnel, the permanent colostomy rate was 30.3%. Concurrent injury to the abdomen strongly predicted long-term colostomy (p = 0.009), along with hypogastric arterial ligation (p = 0.05) and pelvic fracture (p = 0.06). LIMITATIONS: This study was limited by the potential underdiagnosis of anal injury and the restricted follow-up of non-US personnel. CONCLUSIONS: Other injuries besides anal trauma typically have guided the decision for fecal diversion, and acute anal repair has rarely been indicated. The majority of patients with anal trauma regained normal GI continuity, although certain pelvic injuries increased the likelihood of permanent colostomy.

Validation of the Short Musculoskeletal Function Assessment in patients with battlefield-related extremity vascular injuries

OBJECTIVE Vascular extremity injuries can be a significant burden on a patients long-term quality of life. Currently, no limb-specific surveys have been used to quantify the relation between injury pattern and the resultant physical or psychological impact. The objective of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) in the setting of extremity vascular injury. METHODS The Joint Theater Trauma Registry was queried and filtered for U.S. troops with an extremity vascular injury isolated to a single limb. Injury and management data were obtained, and the SMFA was administered after patient contact and consent. Validity was analyzed by characterization of SMFA score distribution, correlation with 36-Item Short Form Health Survey (SF-36) scores, and assessment of its discriminative capability to external measures of injury severity (ie, Injury Severity Score [ISS], Mangled Extremity Severity Score [MESS], and Medicare Part A disability qualification). RESULTS At mean follow-up of 5 years, 164 patients (median age, 25 years; interquartile range, 22-31 years) completed both surveys. The overall SMFA Dysfunction Index was 24.8 ± 15.2 (range, 0-78; skewness, 0.60; floor/ceiling effect, 0%-1.2%; and nonresponse, 0%), and the overall Bother Index was 29.4 ± 20.2 (range, 0-96; skewness, 0.58; floor/ceiling effect, 0%-4.3%; and nonresponse, 0.6%). SF-36 physical component summary scores correlated inversely with the Dysfunction Index (r = -0.64; P < .01), whereas mental component summary scores correlated inversely with the Bother Index (r = -0.59; P < .01). No difference was found in reported scores between those considered severely injured (ISS > 15) and those not severely injured (ISS ≤ 15). However, those with mangled extremities (MESS ≥ 7) reported higher Dysfunction and Bother indices than those with lower scores (P < .05). In addition, patients considered disabled (per Medicare Part A qualifications) reported higher Dysfunction and Bother indices compared with those not considered disabled (P < .05). CONCLUSIONS Use of the SMFA is validated in those with extremity vascular injuries, and it should be considered an adjunctive tool in evaluating long-term patient outcomes.

Magnetic resonance imaging: occult popliteal artery entrapment syndrome in a young soldier.

BACKGROUND Popliteal artery entrapment syndrome (PAES) is frequently misdiagnosed because of symptom overlap with other conditions and lack of a definitive diagnostic modality. The incidence is widely variable, although it should be considered in all patients under 50 years with symptoms of lower extremity claudication. Long-term sequelae of PAES include critical limb ischemia, arterial occlusion, and aneurysm formation caused by repetitive external compression. METHODS We review the case of a 27-year-old soldier originally treated for exertional compartment syndrome with fasciotomies without relief of symptoms. Magnetic resonance imaging (MRI) failed to demonstrate an aberrant slip of the gastrocnemius muscle, which was ultimately found and released on surgical exploration. RESULTS Surgical exploration and release of an aberrant band of gastrocnemius muscle through a medial approach resulted in significant relief of symptoms and improvement of walking distance. CONCLUSIONS Healthy athletes without peripheral vascular disease and symptomatic calf and foot claudication should have an early referral to vascular surgery. The risk of false-negative MRI warrants further investigation into provocative, noninvasive imaging modalities to properly classify PAES. This report reviews the literature to discuss the diagnostic challenges, natural history of disease, and surgical interventions for PAES.

IP235. Transfusion Timing and Postoperative Myocardial Infarction and Death in Patients Undergoing Common Vascular Procedures

Results: In this study, 33 patients (16 diabetic, 17 nondiabetic) who underwent femoral endarterectomy for high-grade occlusive disease were evaluated. No significant difference in key demographics was observed. Tissue plaque FAS content was 69.8% higher in diabetic compared with nondiabetic patients (P 1⁄4 .011); cFAS was also elevated by 41.7% in diabetic patients compared with nondiabetic patients (P 1⁄4 .048). Correlation analysis of 23 patients’ paired samples revealed a significant correlation between cFAS and plaque FAS content (Spearman r 1⁄4 0.4711; r 1⁄4 0.229; P 1⁄4 .023). Conclusions: Our study is the first to evaluate cFAS levels in patients with high-grade, symptomatic, lower extremity peripheral artery disease and demonstrates evidence that cFAS and tissue FAS levels correlate in patients withdiabetes. Future studieswill helpdeterminewhether cFAS is a relevant biomarker for disease severity and progression in diabetic patients.

Combined Arteriovenous Thrombolytic Infusion for Refractory Renal Vein Thrombosis

Acute renal vein thrombosis can rapidly lead to significant impairment and eventual loss of renal function. Classically presenting with flank pain, hematuria, and laboratory markers consistent with acute kidney injury, therapeutic anticoagulation is the mainstay of treatment. However, endovascular surgery offers a safe and effective alternative for renal salvage in the setting of acute renal vein thrombosis. Described is the use of combined arteriovenous thrombolytic infusion for refractory renal vein thromboses to quickly and effectively decrease clot burden in the micro- and macrovenous circulations while limiting systemic exposure.